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Club Cyclone Registration Form

Centenary Wrestling

Name: Address: City:


Telephone H:


Age:_______Grade______Ht____Wt_____ Parent(s) Name(s)____________________ _____________________________________ Emergency Contact: _________________ Phone:______________________________ School Attending:____________________ Parent Signature:____________________ Parent Email :_______________________ Youth Clinic—$180 10 sessions Youth Club (grades 1-8) Start Date: 4/24/12 6:30-8:00 High School Club– $180 10 Sessions HS (grades 9–12) Start Date: 4/25/12 6:30-8:00 Please complete and return the registration, medical release, and liability waiver forms to:

In the past 6 years the Cyclones have seen a lot of success. They are defending Metropolitan Conference Champions and they have been Nationally ranked 4 of the past 6 years. Prior to 2010, the Cyclones did not have an All-American...they have earned 6 over the past three seasons! The Cyclones have also been successful off the mat by finishing each of the past 3 years as an All-Scholar Team and giving back to their communities.

About Club Cyclone We are offering Club Cyclone to give youth and high School wrestlers the opportunity to stay sharp in the off season. We believe that Champions are made in the off season and we would like to help you become a better wrestler! We believe in hard work, developing technique, drilling, conditioning, and of course having fun!


Centenary College Wrestling Office 400 Jefferson Street Hackettstown, NJ 07840 908-852-1400 X-2197 Walk-ons will be accepted with required liability waiver and medical release forms completed upon arrival.

Zeitler Wrestling Facility



Medical Release Form



I herby give permission for ___________________ to participate in the 2012 Centenary College Wrestling Clinic - Club Cyclone. I certify that my son/daughter is in good physical condition,, has been examined within the last 12 months and no medical reason has been found that he can not participate in this camp. Records show that all immunizations are up to date. I understand that he will be participating in rigorous play and activity. Centenary College Personnel have also been informed of any physical limitations, medications or prior conditions. The camp will safeguard the health of my child but will not be responsible for accidents, injuries or sickness on the way to camp, during camp or on the way home.

Asst: Wrestling Coach Centenary College

Head Coach Centenary College

4X Maryland State Place winner

3X New Jersey State Place winner

Undefeated Maryland State Champion

High School All-American 2nd place

High School Record (150-8)

2X NJCAA All-American/National Champion

University Nationals Freestyle

2X NCAA Division I National Qualifier

All-American 5th place

Hofstra Ranked 6th in the Country

4X NCAA Division I National Qualifier

2010 Head Coach of the Year Metro Conference

2010 Asst. Coach of the Year

2008-2009 Centenary Coach of the Year

Metro Conference

2010 Inducted to Hall of Fame Gloucester CC

I agree that in the case of an accident involving my child while attending camp, and with full awareness that wrestling is an activity that may involve risk or injury, I release the 2012 Centenary College Wrestling Clinic - Club Cyclone and Centenary College from any and all liability. I herby request that my child be granted admittance into the 2012 Centenary College Wrestling Clinic - Club Cyclone and authorize the directors to act on my behalf in the event of an emergency requiring medial attention. I will assume responsibility for payment for any such attention and have provided current insurance information as requested. Club members Name:————————————— Age_______ Parent(s) Name(s)_____________________________ Home Phone__________________________________ Emergency Contact____________________________ Relationship____________ Insurance_____________ Policy #________________________________________ By signing below, I agree to all the terms detailed above Parent/Guardian Signature_____________________ Date__________________________________________

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